- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $79.86 / $79.86 / $79.86
| Facility | 26 | $79.86 | $79.86 | $79.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.47 / $236.09 / $388.56
| Professional | | $217.47 | $236.09 | $388.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.95 / $156.76 / $374.14
| Professional | | $72.95 | $156.76 | $374.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.45 / $318.95 / $397.02
| Professional | | $233.45 | $318.95 | $397.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $116.79 / $313.76
| Professional | | $32.34 | $116.79 | $313.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.45 / $304.50 / $397.02
| Professional | | $233.45 | $304.50 | $397.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.04 / $332.20 / $441.61
| Professional | | $250.04 | $332.20 | $441.61 |